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Home > Glossary > determination

determination

What is determination?

determination infographic

What is determination?

Determination in Original Medicare is a reference to either the National Coverage Determination (NCD)1 process or a Local Coverage Determination (LCD) process,2 under which rules are established for what services Medicare will cover.

Medicare Advantage plans are required to cover all services that are covered by Original Medicare, and they can also cover various additional services.3

But Medicare Advantage plans and Medicare Part D plans also have their own coverage determination protocols to ensure, for example, that prior authorization is obtained when necessary, or that an enrollee is using an in-network medical provider if that’s a plan requirement.

Enrollees can request a coverage determination from their Medicare Advantage or Part D insurer, to find out whether a particular service will be covered.4

Related Articles

claim

claim

A claim is an application for benefits provided by your health plan. You must file a claim before funds will be reimbursed to your medical provider. A claim may be denied based on the carrier's assessment of the circumstance.

Who should I contact if I have an issue with my Medicare coverage?

Who should I contact if I have an issue with my Medicare coverage?

You can usually address many Medicare Advantage or Part D enrollment issues by contacting Social Security or 1-800-MEDICARE. But you have to appeal coverage denials directly to your insurer.

claim

claim

A claim is an application for benefits provided by your health plan. You must file a claim before funds will be reimbursed to your medical provider. A claim may be denied based on the carrier's assessment of the circumstance.

Who should I contact if I have an issue with my Medicare coverage?

Who should I contact if I have an issue with my Medicare coverage?

You can usually address many Medicare Advantage or Part D enrollment issues by contacting Social Security or 1-800-MEDICARE. But you have to appeal coverage denials directly to your insurer.

Footnotes

  1. ”Medicare Coverage Determination Process” Centers for Medicare & Medicaid Services. Accessed June 27, 2025 ⤶
  2. ”Local Coverage Determinations” Centers for Medicare & Medicaid Services. Accessed June 27, 2025 ⤶
  3. ”Understanding Medicare Advantage plans” Medicare.gov. Accessed June 27, 2205 ⤶
  4. ”Coverage Determinations” Centers for Medicare & Medicaid Services. Accessed June 27, 2025 ⤶